Office Visits: Not Always Necessary, But Often Best

A brief encounter can build a critical bond.

He called my front desk to schedule an appointment, and through advanced access he was placed in a same-day time slot that afternoon.

Having just recently seen him for his routine checkup where we had dealt with his atrial fibrillation, his diabetes, his hypertension, his obesity and his BPH, I assumed there was some sort of critical illness, some acute crisis that needed attending to.

When he arrived in my office and I came into the room, he said "Doc, can you look at this spot on my forehead, do I need to see my dermatologist?"

He said he had noticed it a couple of weeks ago, and that it has gotten irritated and was bleeding, and hurt when he pushed on it.

On examination, he had what looked to be a basal cell carcinoma not unlike the several dozen previous skin cancers he'd had removed from his face, torso, and arms over the years by his dermatologist.

It didn't look like much of anything else. Not a scab. Not a blister. Not a bug bite.

I told him that this did in fact look like another little skin cancer, and that we should probably send him over to see his dermatologist so they could remove it. He thanked me, and left the office.

Another Approach

Now, under ordinary circumstances, if he had called me and told me he had a new lesion on his forehead and that it looked like another skin cancer, we could've avoided the office visit altogether.

If he sent me a high-resolution image of the lesion taken with his phone, and I'd had images of his forehead from a previous visit that showed no lesion there, we could've dispensed with the office visit altogether.

Or, if knowing that he had a history of multiple skin cancers I just called his dermatologist, they more than likely would have had him come in.

I could've gotten fancy, and taken a picture of the lesion myself and forwarded it through our electronic health record to his dermatologist, but I was pretty sure that they would want to see the guy and his forehead in their office for definitive treatment.

This was not something they were going to put a little triamcinolone on and call them in the morning.

Virtual Versus Actual

As we are changing the model of access to care, where patients can get to us and get care from us electronically through email, their phones, patient portals, and other widgets still unknown, we have to wonder how much care we're willing to accept over these devices, and how much do we really depend on the physical presence of the patient in our office.

Before we even get started thinking about this, we have to recognize that we need to challenge our model of reimbursement to address this problem, given that if I avoid this office visit and take care of this problem through a patient portal and send him directly to his dermatologist, I would not be paid.

When the patient sends their dermatologist a picture of a rash, and the dermatologist sends a cream to the pharmacy, the dermatologist doesn't get paid.

There is something inherently reassuring about seeing the patient in the office. It was important to him that he saw me, that he asked me, his longtime primary care provider, what I thought about this. If I probed, I probably would've found out that he suspected that this was another basal cell carcinoma, and if I pushed him I could've said, did you think of just calling your dermatologist yourself?

I've taken care of him for over a decade, he and I have been through a lot of his health challenges together. I don't believe he thinks that if he had called me and asked if he should see his dermatologist directly about something on his forehead, that I would have nickeled-and-dimed him, made him come in to get an opinion.

The Critical Link

But this opinion, this relationship, the strength of this bond, does add something to healthcare, and is a critical link that we risk losing as we continue to advance and change how medical care may be delivered in the 21st-century.

If the majority of the care our patients receive is through a portal, a device, a sensor, or interim providers they do not know, we risk losing that personal connection, and I think that's potentially a devastating loss to the system.

I'm all for cool new technology, and if he held his phone up to his forehead, and I saw a live video feed of the lesion he was worried about, then patched it over to his dermatologist, and avoided making him come in to see me in the office, then all the better.

But we need to make sure that insurers and other payers recognize that this is work and effort and requires our expertise, and is something of worth that we bring to the system.

As we create more and more opportunities for our patients to get care beyond the traditional office visit, we need to recognize that these add value, improve quality, and increase patient satisfaction, but that they also come with a cost.

Barraged every day by multiple in-baskets, emails, patient messages, and more, these things take up a provider's time, our intellectual energy, and ultimately we are held responsible for the medical decision-making that goes on in all of these interactions.

Almost every provider has been involved in a non-office visit healthcare encounter where what they told the patient ended up causing a complication or some other problem, and I think we all are moving towards this new model of expanded access and multiple interaction mechanisms with our patients with a bit of trepidation.

Value our time, reward our time, and we will help move these new modalities forward.

But if they just make more work for us, then it will only add to the burnout currently experienced by overwhelmed primary caregivers.

Already smart phones are being used to monitor cardiac rhythms, and new digital devices are coming on the market to follow a broad array of patient's vital signs. I envision a time when a patient is going be all able to hold their smartphone up to their own lungs and let us remotely hear the rhonchi, the wheeze, the rales. Is it going to be okay at that point for us to manage their pneumonia, their asthma, or their heart failure over the phone?

We do this now to a lesser degree, and with significantly less data, when a patient calls us up and we talk with them, make an educated clinical guess about what's going on and try empiric treatment at home, but still there is something to be gained by having the patient come in and let us lay our eyes, our hands, our stethoscopes on them.

At the conclusion of our visit that day, I told him that if he saw something that he thought his dermatologist should see, he could call me (or his dermatologist) up, and I showed him how he could take a picture and send it to me on his phone, and he was reassured, but I think also grateful for the ability to come in and see me.

And actually, I think this paid off, because one week later, he developed gross hematuria, and I think in the back of his mind he knew that it was going to be okay to call me and come in to be seen that day.

Definitely did not want a selfie of gross hematuria.

Whatever model of access and innovative technology we move towards in the future, we need to take them with a grain of salt, and not abandon the traditional office visit completely.

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